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  • Care of the Patient with Ocular Surface Disorders

    OPTOMETRIC CLINICAL PRACTICE GUIDELINE

    OPTOMETRY: THE PRIMARY EYE CARE PROFESSION

    Doctors of optometry are independent primary health care providers who examine, diagnose, treat, and manage diseases and disorders of the visual system, the eye, and associated structures as well as diagnose related systemic conditions. Optometrists provide more than two-thirds of the primary eye care services in the United States. They are more widely distributed geographically than other eye care providers and are readily accessible for the delivery of eye and vision care services. There are approximately 32,000 full-time equivalent doctors of optometry currently in practice in the United States. Optometrists practice in more than 7,000 communities across the United States, serving as the sole primary eye care provider in more than 4,300 communities. The mission of the profession of optometry is to fulfill the vision and eye care needs of the public through clinical care, research, and education, all of which enhance the quality of life.

  • OPTOMETRIC CLINICAL PRACTICE GUIDELINE

    CARE OF THE PATIENT WITH OCULAR SURFACE DISORDERS Reference Guide for Clinicians

    First Edition Originally Prepared by (and Second Edition Reviewed by) the American Optometric Association Consensus Panel on Care of the Patient with Ocular Surface Disease: Clifford A. Scott, O.D., M.P.H. (1st edition only) Louis J. Catania, O.D K. Michael Larkin, O.D. (1st edition only) Ron Melton, O.D. (1st edition only) Leo P. Semes, O.D. Joseph P. Shovlin, O.D. Edited and revised by: Leo P. Semes, O.D., Principal Author David C. Bright, O.D. C. Denise Pensyl, O.D., M.S. Reviewed by the AOA Clinical Guidelines Coordinating Committee: John C. Townsend, O.D., Chair (2nd Edition) John F. Amos, O.D., M.S. (1st and 2nd Edition) Barry Barresi, O.D., Ph.D. (1st Edition) Kerry L. Beebe, O.D. (1st Edition) Jerry Cavallerano, O.D., Ph.D. (1st Edition) John Lahr, O.D. (1st Edition) W. Howard McAlister, O.D., M.P.H. (2nd Edition) Stephen C. Miller, O.D. (2nd Edition) David Mills, O.D. (1st Edition) Approved by the AOA Board of Trustees March 23, l995 (1st Edition) and November 8, 2002 (2nd Edition); Updates to Guideline – April and June 2003 © American Optometric Association 1995, 2002 243 N. Lindbergh Blvd., St. Louis, MO 63141-7881

    Second printing February 1996 Printed in U.S.A.

    NOTE: Clinicians should not rely on the Clinical Guideline alone for patient care and management. Refer to the listed references and other sources for a more detailed analysis and discussion of research and patient care information. The information in the Guideline is current as of the date of publication. It will be reviewed periodically and revised as needed.

  • Ocular Surface Disorders iii

    TABLE OF CONTENTS INTRODUCTION...................................................................................1 I. STATEMENT OF THE PROBLEM...........................................3

    A. Description and Classification of Ocular Surface Disorders ..............................................................................4 1. Normal Lid Margin Anatomy....................................4 2. Normal Tear Film Composition.................................4 3. Dry Eye-Related Ocular Surface Disorders ...............5

    a. Aqueous Deficient Dry Eye ............................6 b. Mucin Deficient Dry Eye ................................7 c. Lipid Abnormality Dry Eye ............................8 d. Surfacing Abnormalities .................................8 e. Epitheliopathies...............................................8 4. Blepharitis-Related Ocular Surface Disorders...........9 a. Staphylococcal Blepharitis ..............................9 b. Seborrheic Blepharitis .....................................9 c. Seborrheic/Staphylococcal Blepharitis..........10 d. Meibomian Seborrheic Blepharitis................10 e. Seborrheic Blepharitis with Secondary

    Meibomianitis...............................................10 f. Meibomian Keratoconjunctivitis ..................10 g. Angular Blepharitis.......................................11 h. Demodicosis .................................................11 B. Epidemiology of Ocular Surface Disorders .......................11 1. Dry Eye ....................................................................11 a. Prevalence.....................................................11 b. Risk Factors ..................................................12 2. Blepharitis................................................................13 a. Prevalence.....................................................13 b. Risk Factors ..................................................13 C. Clinical Background of Ocular Surface Disorders.............13

    1. Dry Eye....................................................................14 a. Natural History .............................................14 b. Signs, Symptoms, and Complications ..........14 c. Early Detection and Prevention ....................15 2. Blepharitis................................................................15

    iv Ocular Surface Disorders

    a. Natural History..............................................15 b. Signs, Symptoms, and Complications...........16 c. Early Detection and Prevention.....................17 II. CARE PROCESS .......................................................................19 A. Diagnosis of Ocular Surface Disorders..............................19 1. Patient History .........................................................19 2. Ocular Examination for Dry Eye.............................20 3. Ocular Examination for Blepharitis.........................25 B. Management of Ocular Surface Disorders .........................27 1. General Considerations............................................27 2. Management of Dry Eye..........................................28 a. Basis for Treatment .......................................28 b. Available Treatment Options ........................29 3. Management of Blepharitis......................................34 a. Basis for Treatment .......................................34 b. Available Treatment Options ........................35 4. Patient Education .....................................................36 5. Prognosis and Followup ..........................................37 CONCLUSION .....................................................................................39 III. REFERENCES ...........................................................................40 IV. APPENDIX .................................................................................51

    Figure 1: Optometric Management of the Patient with Ocular Surface Disorders: A Brief Flowchart.....................51

    Figure 2: Frequency and Composition of Evaluation and Management Visits for Dry Eye ..............................52

    Figure 3: Frequency and Composition of Evaluation and Management Visits for Blepharitis ..........................53

    Figure 4: ICD-9-CM Classification of Dry Eye and Blepharitis................................................................54 Abbreviations of Commonly Used Terms....................................56 Glossary........................................................................................57

  • Introduction 1

    INTRODUCTION Optometrists, through their clinical education, training, experience, and broad geographic distribution, have the means to provide effective primary eye and vision care for a significant portion of the American public and are often the first health care practitioners to diagnose ocular surface disorders. Although some classifications use “ocular surface disease” in the context of clinical damage to the intrapalpebral surface, that term is not universally understood. In this Guideline, the term “ocular surface disorders” encompasses a number of disease entities, some specific and some nebulous. These disorders range from poorly defined contributors to ocular surface discomfort (either direct or indirect disruptors of the tear film) to nonspecific entities described elsewhere as ocular surface disease, to dry eye, including aqueous deficiency secondary to systemic causes (e.g., any of the family of collagen vascular diseases) that may result in dry eye. As knowledge expands and classification systems change, this terminology continues to evolve. This Optometric Clinical Practice Guideline for the Care of the Patient with Ocular Surface Disorders describes appropriate examination and treatment procedures to reduce the risk of visual discomfort and disability from these entities. The most common ocular surface disorders stem from tear film abnormalities and blepharitis, each of which may lead to ocular surface disease. The Guideline contains recommendations for timely diagnosis, treatment, and, when necessary, referral for consultation with or treatment by another health care provider. This Guideline will assist optometrists in achieving the following goals: • Identify patients at risk of developing ocular surface disorders • Accurately diagnose patients with ocular surface disorders • Differentially diagnose age, drug, environmental, and systemic

    disease-related causes of ocular surface disorders • Improve the quality of care rendered to patients with ocular su